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Sufali et al. Vessel Plus 2024;8:16 https://dx.doi.org/10.20517/2574-1209.2023.139 Page 5 of 14

To ensure good spinal cord perfusion, two more anesthesiological measures were adopted in all cases: the
maintenance of perioperative high mean arterial pressure > 80 mm Hg, and blood hemoglobin levels
> 10 mg/dL.

Every patient was continuously monitored in the Intensive Care Unit (ICU) for at least 24 h in the
postoperative period.

Neurological measures
Each patient received a neurological evaluation on admission, after every step, and before discharge.
Neurologic evaluation was performed every hour at the bedside by specialized nurses in the ICU, and every
4 h by medium care nurses until the removal of the CSFD. Thereafter, a physician of the vascular team
evaluated the patient at least every 12 h.

If there were signs of neurological deficits, they received promptly further evaluated by a neurologist.
Following this evaluation, and typically upon the prescription of the neurologist him/herself, a magnetic
resonance imaging (MRI) was usually conducted.

Intraoperative neuromonitoring via SSEPs/MEPs represents a way to detect SCI prior to irreversible
damages occurring and to promptly initiate corrective measures [11,17] . SSEPs/MEPs were introduced in 2019
in our department. Its use is limited by the availability of the service, provided by a specialized team of
neurologic technicians. In case of SSEPs/MEPs decrease during the procedure, immediate rescue maneuvers
include the optimization of blood pressure and hemoglobin levels, downsizing of femoral sheaths as soon as
possible to restore pelvic circulation, drainage of cerebrospinal fluid through CSFD, and, most importantly,
staging of the procedure if not already planned for the specific case.

Endpoints and definitions
The primary endpoint was the incidence of SCI after F/B-EVAR. SCI was defined as the onset of transient
paraparesis or paraplegia after TAAA repair, not explained by other causes. SCI was considered permanent
in the presence of any residual neurologic deficit (motor or sensitive). Neurological deficits were classified
according to Tarlov’s Modified Scale.

The secondary endpoints were the rate of cardiac and pulmonary morbidities, the need for hemodialysis,
and the combined 30-day/in-hospital mortality after F/B-EVAR. Survival was also evaluated during follow-
up.

Preoperative comorbidity and postoperative complications were classified according to the Society of
“Vascular Surgery Reporting Standards .
[18]
Several clinical characteristics were collected for every patient, including sex, history or current tobacco use,
hypertension (systolic blood pressure > 140 mm Hg and/or diastolic pressure > 90 mm Hg or
antihypertensive drugs use), dyslipidemia (total cholesterol > 200 mg/dL or low-density lipoprotein
> 120 mg/dL or lipid-lowering drugs use), coronary artery disease (history of angina pectoris, myocardial
infarction, or coronary revascularization), diabetes mellitus (medical treatment with insulin or oral
hypoglycemic drugs), chronic kidney disease (CKD) (estimated glomerular filtration rate < 60 mL/min),
chronic obstructive pulmonary disease (chronic bronchitis or emphysema), peripheral artery obstructive
disease (lower limb claudication or rest pain or ischemic ulcer with confirmation of arterial disease at
duplex ultrasonography or previous peripheral artery revascularization). Single or double antiplatelet
therapy and oral anticoagulant therapy were also registered.